Ramblings of an Emergency Physician in Texas

Organ Donation

Organ donation is one of those topics that actually encompasses several connected but different elements. I believe most people think of brain-dead to live transplant when it comes up, but there are also living donor transplants, where awake donors can give their organs (kidney and liver lobe are, I think, all that are routinely done currently).
People need transplants to live, or to improve their quality of life. Others die and their perfectly good organs get buried with them. The problem has always been how to increase the donations in an acceptable manner. Not even the most zealous advocates of donation would support involuntary donation, so education and persuasion are the tools most used to promote donation, although some legislation has been brought forward, but in a pretty rational way, mostly requiring hospitals to notify the family that ‘organ donation is available, are you interested?’ kinds of things.

What can be done to increase organ donation? Talk to your loved ones about it. Make your wishes very clear, so there is no misunderstanding. I think the Drivers’ License check boxes that say ‘I want to be an organ donor’ are very nice, and an excellent way to sensitize people to the idea, but no organ donation society is going to rely on that check box alone. It would be useful to stimulate a conversation with the family, but just remember that you are not going to be having this discussion about your organs, your family will. Donor groups will pass up good organs if there is family hostility to the idea (imagine the damage done with a couple of headlines “organs taken against our wishes”), but they’re very good at talking to people. Durable Powers of Attorney for Health Care might help, but again, if those left behind say no, that’ll be the end of that donation.

The emotional trauma in the donor family cannot be underestimated, and that’s before the idea of donation is brought up. The donor was usually healthy, with a good future and was struck down suddenly; there is nearly always anger toward God, or the other driver / shooter, etc. and often toward the treating doctors and nurses. They don’t really believe we’re responsible for the injury, but the looks in the eyes and the questions scream “why can’t you bring him back / we thought you could do more / if only you had…” and the docs and nurses feel the weight of accusation and disappointment, justified or not. It makes communication with the families just that much harder.

This hostility toward the treating team is one of several reasons that donation will nearly never be brought up my the docs and nurses, but by a very well trained, experienced organ donation rep. They are usually notified of an impending brain death by the nurses. I have no problem with this, as I’ve see how it works, but I can see how this sounds. We’re not vultures, and nobody would ever not-do-everything until the determination of brain death is made.

What needs to happen before a patient becomes a donor? It’s astonishingly complicated, and the organ donation people are startlingly good at getting a lot of things done efficiently, and at no cost to the donor. First, the cause of death: if it’s overwhelming infection, forget it (cannot transplant an infection). Consider the attributes of an ideal donor: no chronic diseases, no medications before hospitalization, no cardiac arrest, no overwhelming infection, and brain dead. Cardiac arrest removes several organs from transplantability (not to be confused with time after harvesting before trasnplantation: it’s true that kidneys can go about 6 hours before transplantation, but they have to be removed with a pulse and correctly preserved). Several tissues can be taken from dead donors, and they are very important; hearts can yield transplantable valves, bone used for reconstruction, etc.

Where do these donors come from? Accidents, nearly all of it blunt trauma with severe head injuries, with gunshot wounds to the head and drowning as possibilites. Who is this person? The 20 y/o male non-helmet wearing motorcycle rider comes to mind, and I cannot see a biker sans helmet without thinking about the topic of organ donation. Attempted suicide by firearm is another group; I have heard conflicting tales regarding homicide GSW’s to the head, but the organ donor people would know. Chronic diseases are reviewed on a case by case basis, but HIV is an absolute disqualifier, hepatitis would knock out liver donation (but possibly not some other organs), etc. Age is not an absolute disqualifier (some older kidneys work terrifically well), but with age come more and more chronic conditions that need to be assessed. All this is screened for by the organ donation staff after THEY approach the patient’s family and agree to at least consider donation, and then blood tests are run by the Donation Team to assess all of the above, plus more.

If and when the family agrees, nothing changes in the patient’s management until they are pronounced dead. This is important, and people need to understand that nobody stops resuscitation to facilitate organ donation. Once the patient is declared brain dead, they are no longer a patient; they’re dead, but have a pulse and a blood pressure. (I’m aware there are different criteria for declaring death / brain death, and that’s not my talk today). Minute to minute management of the donor then goes to the transplant team, which usually has an experienced ICU nurse or two to sustain BP and pulse, etc, until the transplants can be done.

I am for organ donation, and have discussed this with my family. I don’t think it’s going to make everything all right for the donor’s family, but can be a way for something good to come from tragedy. Again, talk to your family, because when it counts they’re going to be talking for you.

Update: the timeline for the brain-dead to live donation is usually a couple of days, in order to affirm, and to affirm to families, that nothing more can be done. It’s not a shoot from the hip, quick decision. Another reason donations fail is that patient’s wishes get filtered through the scrapbook of loss and grief, and come out however the survivors want. The vast majority of young, healthy people are bulletproof and believe they will live forever, and have never even thought this could happen to them, much less discussed it with their loved ones.

Organ Donation has no shortage of really good websites. Some of the above was gleaned from the following websites; any errors in the blog posting are mine.